SMI life expectancy reduced by years compared to the general population (Vancampfort et al., 2013; Wahlbeck et al., 2011)

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1 A Pilot Study Examining the Validity of the local Nutritional Screening Tool within an Inpatient Mental Health and Learning Disability Setting in Comparison to Malnutrition Universal Screening Tool (MUST). Jennifer McIntosh

2 Background SMI life expectancy reduced by years compared to the general population (Vancampfort et al., 2013; Wahlbeck et al., 2011) People with LD 58 x more likely to die before 50 (Camus, 2008) People with a mental illness and / or LD are at higher risk of obesity, malnutrition and serious health problems compared to the general population (Disability Right Commission, 2006; Emerson & Baines, 2010; Public Health England, 2013) 18% of adults malnourished on admission to MH units (Bapen 2010)

3 Background Early detection of under and over nutrition is vital with NSTs seen as the most effective first line approach (NICE, 2012). LYPFT developed their own NST 8-9 years ago But never validated to understand reliability, specificity and / or accuracy for this population

4 Literature Search Lack of studies on malnutrition with the exception of dementia Few quality quantitative research particularly in LD Majority focus on specific conditions and involve small sample sizes making it difficult to generalise.

5 Literature Search No international consensus on a single best NST (Van Bokhorst-de van der Schueren et al p.33) Majority of NSTs assess malnutrition (Weekes et al 2004; Mueller et al., 2011). MUST not validated for MH and LD setting and excludes adolescents (BAPEN 2012) 4 NST studies set in MH and LD settings (Rowell et al 2012; Tsai et al., 2011; Walker, 2009; Bryan et al., 1998)

6 What is Validation? (NICE 2012) Measures what it is intended to measure Measurements are reproducible User friendly Developed by MDT No clear standardisation for validation due to no clear method of analyses (Jones 2004) In the absence of a gold standard reference methods used e.g. another NST or objective assessment via a professional (Van Bokhorst de van der Schueren et al 2014)

7 Prospective cross sectional study Aim: To test the validity, reliability, specificity and accuracy of LYPFT NST compared to MUST in the absence of a gold standard

8 Objectives 1) To determine whether LYPFT NST is more sensitive for service users with MH or LDs compared to MUST. 2) To determine whether LYPFT NST is sensitive across all age groups. 3)To determine whether LYPFT NST measurements are reproducible. 4) To determine whether LYPFT NST identifies both malnutrition and / obesity in comparison to MUST.

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10 LYPFT nutritional screening tool Weight and height measurements: Nutritional Screening Person Details Name Header Details Referral Date BMI Measurements Weight (kg) within last 5 days Height (metres) BMI Unable to check weight/height at present? Yes No If unable to check weight / height enter reason why. DOB Received Date Any co-morbidities? These could be: Yes No Type 2 diabetes Hypertension (raised blood pressure) Coronary Vascular Disease Abnormal lipid levels Osteoarthritis Sleep apnoea BMI SCORE

11 NST Questions Nutritional Screening Risk 1. Has the patient experienced significant WEIGHT LOSS due to mental or physical health over the past 3 months (e.g. more than 3kg/half a stone, if underweight)? 2. Has the patient experienced a significant unintentional WEIGHT GAIN over the past 3 months (e.g. more than 6kg/one stone, if overweight)? Score Yes No Yes No 3. Is the patient currently on a nutritional supplement, receiving enteral feeding, eating less than half of their meals or refusing to eat? 4. Does the patient have medical reasons for a special diet e.g. diabetes, food allergy, coeliac disease, acute crohns, COPD, cancer, iron deficiency anaemia? If yes drop down box to write in type of diet (free text) 5. Does a visual assessment of the patient suggest under nourishment? (Low body weight, loose fitting clothes, fragile skin, poor wound healing, pressure sores) 6. Does the patient have excessive fluid losses through vomiting and or diarrhoea, or excessive drooling, constipation? 7. Does the person need assistance to eat or drink? Yes No Yes No Yes No Yes No Yes No

12 NST Risk Score and Outcome NUTRITIONAL RISK SCORE Nutritional Screening Action (*help button Refer to dietetics according to clinical pathway. Advice available from local dietitian) Type of referral: Initial Review Discharge Nutritional Screening Score: 0-2 NO RISK Promote healthy lifestyle 3-5 MEDIUM RISK Refer to dietetics 6+ HIGH RISK Urgent referral to dietetics Interventions: Trust Dietetics Dietetics via GP Other Decline

13 Methodology Procedure: Over a week LYPFT NST completed via staff plus expert dietitian as per routine practice. Sampling: Convenience sample e.g. everyone who is on the ward over the selected week with consent. Sample: Sample size calculation 202 BUT reduced to 100 and renamed pilot!

14 Methodology Participants: All service users within inpatient setting across the following areas; Adolescents LD Inpatients & supported living services Rehabilitation & Recovery services Older people acute MH wards Adult acute MH wards

15 Methodology Inclusion: All inpts across selected wards Supportive living services LD 13 years to older age Exclusion: Outpatients Eating Disorders unit Those lacking in capacity

16 Results: Characteristics Criteria Proportion of Sample n=90 Age (years) mean (SD) 46 (23.10) Male 45 (50) Female 45 (50) White British 71 (78.9) Primary Diagnoses (%) Eating disorders 5 (5.6) Learning disability ** 12 (13.3) Depressive disorder 23 (25.6) Personality Disorder*** 5 (5.6) Anxiety Disorder 2 (2.2) Cognitive impairment **** 7 (7.8) Bipolar Affective Disorder 9 (10) Psychosis 19 (21.1) First episode psychosis 5 (5.6) Other 3 (3.3)

17 Location of Participants 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Research Participants

18 Objective 1: DIAGNOSIS Other (n=3) 1st Episode Psychosis (n=5) Psychosis (n=19) Bipolar (n=9) Cognitive Impairment (n=7) Anxiety Disorder (n=2) NST 3+ MUST Personality Disorder (n=5) Depressive Disorders (n=23) LD (n=12) Eating Disorders (n=5)

19 Objective 2: AGE years years years MUST LYPFT NST years

20 MUST & AGE GROUPS under nutrition over nutrition no risk yrs yrs yrs yrs

21 LYPFT NST AND AGE GROUPS undernutrition over nutrition No Risk yrs yrs yrs yrs

22 Objective 3: Reproducibility Inter-rater reliability demonstrated a statistically strong correlation meaning a strong relationship between NSTs completed by the member of staff and dietitian P< 0.000, r= 0.93 Cronbach s alpha demonstrated a high level of agreement between the members of staff and the dietitian of 0.96.

23 Objective 3: Reproducibility Kappa measure of agreement: 5/9 statistically very good agreement: comorbidity; weight loss; weight gain; special diet and overall outcome. 2/9 moderate agreement: nutritional supplement and visual assessment. 2/9 could not calculate answers due to lack of a constant: requiring assistance to eat and fluid losses

24 Objective 4: Obesity/Malnutrition BMI kg/m 2 and Gender Criteria Male Female Total Mean Range

25 Differences between MUST and LYPFT NST Detecting Malnutrition and Obesity < BMI BMI BMI MUST LYPFT NST BMI >BMI

26 Sensitivity of MUST to Detect Nutritional Risk across BMI BMI 40+ BMI BMI BMI under BMI 18.5 Undernutrition Over nutrition No Risk 0% 50% 100%

27 Sensitivity of LYPFT NST to Detect Nutritional Risk across BMI BMI 40+ BMI BMI BMI undernutrition overnutrition no risk under BMI % 50% 100%

28 Discussion 1. Recruitment 65 recruited after a week. Recruitment period extended by 2 weeks increasing total to Capacity Two thirds of service users lacked capacity to consent. Fluctuating nature of capacity (Murray, 2013) Understanding of capacity varied (Murray, 2013; Shepherd, 2016).

29 Discussion 3. Completion of NSTs Staff standardly complete LYPFT NST in isolation. 4. Comorbidities 26.7% had a comorbidity reported compared with national figures 68%.

30 Objective 1 & 2 Both NSTs were similar at identifying those at nutritional risk across all diagnoses with LYPFT NST being more sensitive across depressive disorders LYPFT NST appeared more sensitive across all age groups with the exception of year olds. Criterion validity (p=0.00, rs = 0.56) indicted a strong correlation between MUST and the local NST completed via the Dietitian, indicating LYPFT NST valid for this population.

31 Objective 3 & 4 Inter-rater agreement between the dietitian and staff showed was statistically significantly indicating good reproducibility. Both NSTs showed a statistical difference for malnutrition and obesity compared to a healthy weight but LYPFT NST was more sensitive and specific.

32 Conclusion The study highlighted a gap in nutritional screening. No consensus on how to validate NSTs with huge variation in the types of validation and reliability methods used across studies (Elia & Stratton, 2012). LYPFT NST showed strong reproducibility between staff and dietitian. Strong indication LYPFT NST was valid, sensitive and specific for this population compared with MUST (NICE, 2012). Gives assurance regarding the quality of the local NST for use within this population, however inconclusive as a pilot study

33 Recommendations Improvements to LYPFT NST BMI 30-35kg/m2 indicate automatic referral to dietetics Development of a service user friendly LYPFT NST aiding partnership working Training opportunities Development of peer sessions for all staff aiding standardisation

34 Next Steps Future Research Extend the study with a larger sample size including those who do not have capacity and lengthening the recruitment by 1 month.